J Byrne Insurance Agency

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"Boat Insurance Questionnaire"

Boat Insurance Questionnaire
Please take five minutes of your time to find how much you can save. It is understood that this is not an application for insurance. There is no obligation and no sales person will call or visit me.		J. Byrne Agency, Inc. 5200 New Jersey Ave., Wildwood, NJ 08260 Phone 609-522-3406 / Fax 609-522-2844 Website: www.jbyrneagency.com

OPERATOR INFORMATION
Operator #1
Name :	Birthdate:
Drivers License #:	State:
List Prior Boats owned from biggest to smallest - (must enter length, manufacturer, model and years owned)

Total Years Operating Boats:	Total Years as a Boat Owner:
Prior Boat Losses: If yes give date, loss description, how much was paid out.	Boater Safety Courses? :	Yes No

Any Motor Vehicle Violations in the Last 3 Years?
If yes, please explain:

BOAT INFORMATION
Year:	Length:	Manufacturer:
Model:
Exact Mooring Location - Winter (List Marina, Residence, City, State, Zip)
Exact Mooring Location - Summer (List Marina, Residence, City, State, Zip)
Lay-up Period:
Navigation Area:
Navigation Comments:
Boat Construction:
Purchase Date:	Purchase Price:
Date of Last Survey: If within 2 years old must provide a copy to be able to quote. Fax to 609-522-2844 or send by email to cdouglass@jbyrneagency.com

EQUIPMENT INFORMATION
Select ALL That Apply: Loran Halon(co2) VHF Radar Anti-Theft EPIRB
	Other Please describe:

GENERAL INFORMATION
Any Paid Crew?
Any waterskiing or tubing?		Percentage of use for skiing or tubing:
Any Charters?		How many charters per year:

LIMITS OF COVERAGE
Hull Limit Including Electronics:	Optional Coverage:	Yes
Liability:	Fishing Equipment:

FAIR CREDIT STATEMENT
Note: You must agree to the following terms in order to use this service. Please read the statement below, carefully - before proceeding.
I understand that the J. Byrne Agency, Inc. on behalf of the Insurance Company will order an investigative consumer report as part of the underwriting process to qualify, evaluate, and quote my insurance coverage. Various consumer reports such as motor vehicle reports, credit reports, and claim history with prior insurance companies, may be obtained. In the event that the coverage is denied based on information in one of these reports, I will be advised of this and given the name and address of the consumer agency making the report. Please note: The price estimate (or quote for insurance coverage) provided to you by the J. Byrne Agency, Inc. will be base on the information supplied by you on this application. I Have Read the "Fair Credit Statement - and I AGREE to the terms set forth. WARNING: Do NOT Continue without checking the box above. You will not be able to continue and the answers to the questions you just answered may be lost.

Wildwood, NJ
5200 New Jersey Avenue
PO Box 1409
Wildwood, NJ 08260
Phone (609) 522-3406
Fax (609) 522-2844

Marmora, NJ
200 Route 9 South, Unit 1
Marmora, NJ 08223
Phone (609) 390-5566
Fax (609) 390-5577

Cape May Court House, NJ
1032 Route 9 South
Cape May Court House, NJ 08210
Phone (609) 465-7710
Fax (609) 465-9346

Cape May , NJ
917 Madison Avenue
Cape May, NJ 08204
Phone (609) 884-3333